Nokea
The postoperative client on hydrocodone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client?
- A. Client's respiratory status 60 minutes later
- B. Documenting the client's hypoxic event
- C. Obtaining an order for a different analgesic
- D. Potential for drug-drug interaction now
Correct Answer: A
Rationale: After naloxone administration for opioid-induced hypoxia, monitoring respiratory status is critical as naloxone's effects are short-acting, and respiratory depression may recur. Documentation is important but secondary, changing analgesics is not immediate, and drug interactions are less urgent.
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Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to parents of a toddler about readiness for toilet training?
- A. The child learns voluntary sphincter control through repetition
- B. Myelination of the spinal cord is completed by this age
- C. Neuronal impulses are interrupted by the ganglia
- D. The toddler can understand cause and effect
Correct Answer: B
Rationale: Myelination of the spinal cord is completed by this age, enabling voluntary sphincter control between 18 to 24 months.
The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
- A. Arterial septal defect
- B. Patent ductus arteriosus
- C. Aortic stenosis
- D. Ventricular septal defect
Correct Answer: D
Rationale: Ventricular septal defect. Surgical repair involves manipulation of the ventricular septum, increasing the risk of conduction disturbances.
The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, 'It hurts too much. I can't do it.' Which action should the nurse complete first?
- A. Administer a PRN analgesic and monitor for adverse effects
- B. Ask the client to point to a numeric scale to indicate pain level
- C. Come back later in the day to attempt ambulation again
- D. Encourage the client to walk to promote blood circulation
Correct Answer: B
Rationale: Assessing pain level using a numeric scale is the first step to quantify the child's pain and determine the need for analgesics or other interventions. Administering analgesics without assessment is premature, delaying ambulation avoids addressing pain, and encouraging walking ignores the child's distress.
The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
- A. Apply dressing using sterile technique
- B. Improve the client's nutrition status
- C. Initiate limb elevation and compression
- D. Begin proteolytic debridement
Correct Answer: B
Rationale: The goal of clinical management in a client with venous stasis ulcers is to promote healing. This only can be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help.
The nurse notes all of the following. Which should be attended to first?
- A. A blind client is calling out stating that she cannot find the call bell.
- B. There is a water spill on the floor near the bed of an elderly client who ambulates regularly.
- C. A postoperative client is asking for pain medication.
- D. A diabetic client is asking for a glass of water.
Correct Answer: B
Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.